This was a cross-sectional study. Physical therapists from Belo Horizonte, Minas Gerais, Brazil, who work with patients with respiratory dysfunction regardless of age, sex, race, socioeconomic status, year of graduation, and professional degree were recruited. Exclusion criteria were: the inability to understand the questionnaire or refusal to participate in the study. All participants gave written informed consent and their rights were protected. The study was approved by the Ethics Committee of the Universidade Federal de Minas Gerais, Brazil (CAAE: 65200717.7.0000.5149).

A self-administered questionnaire of 14 multiple-choice questions was developed by three professionals who had clinical and research experience in the respiratory physical therapy field. The questionnaire was used as a tool to outline the knowledge of physical therapists working with patients with respiratory dysfunctions in Minas Gerais. Furthermore, socio-demographic data (age, working hours, year of graduation, professional degree, length of professional experience with patients with respiratory dysfunction, and characteristics of the working institutions) were also collected to better describe this study's sample. The questionnaire also included questions about the use of scientific literature in English and the frequency of access to scientific databases.

The questionnaire addressed topics already well established in the scientific literature regarding ISs. Questions regarding clinical practice concepts such as aims, indications, contraindications, and instructions provided to patients for the use of ISs were based on the last clinical practice guideline for IS use1 and on the paper by Armstrong.3 For the contraindications, we have also used the study of Goldstein et al.15 to support the questionnaire's alternatives on IS use by patients with tracheostomy. Questions regarding the rationale behind the superiority of volume-oriented IS when compared to flow-oriented IS were based on the latest studies of Paisani et al.,11 Lunardi et al.,12 and Parreira et al.10

Data collection took place in 13 hospital and non-hospital institutions (public and private). The aims and procedures of this study were clarified to the managers of the services who were asked to encourage physical therapists to participate in the study. It was agreed that the feedback on results would be provided through scientific publications as aggregate data and not individually, as this study aimed to provide a broad overview of the knowledge of physical therapists working with patients with respiratory dysfunctions.

The initial contact with the physical therapists was made by telephone or e-mail, with the subsequent distribution and collection of questionnaires made in person. Participants were instructed not to leave questions unanswered and to respond to the questionnaires individually and without consultations. They were also instructed to choose only one alternative for each question, except for one of the questions, in which they were informed that more than one answer would be accepted.

The researchers distributed and recollected the self-administered questionnaires from the participants using opaque and sealed envelopes to maintain the confidentiality of the responses and the anonymity of the participants.

The sample was non-probabilistic and based on the percentage of registered professionals and/or specialists in respiratory physical therapy in Minas Gerais, obtained via the Brazilian Association of Cardiorespiratory Physiotherapy and Physiotherapy in Critical Care (ASSOBRAFIR), which supported this study. A finite population of 210 physical therapists was estimated for the state of Minas Gerais with an assumed proportion of 50% in Belo Horizonte. The calculation determined a sample size of 137 physical therapists based on a margin of error of 5%. The proportion of 50% was adopted because the distribution of physical therapists in the state of Minas Gerais was unknown and this was a conservative approach.16

Descriptive statistics were presented as measure of central tendency (mean), variability (standard deviation), and frequencies. The normality of data distribution was verified by the Shapiro-Wilk test. Comparisons between professionals from public versus private institutions were performed using the difference of two independent samples proportions test. To evaluate bivariate associations between participant characteristics (age, time of professional experience, workplace, higher professional degree, and use of scientific literature in English) and the number of errors on the questionnaire, the Spearman correlation coefficient was used. The strength of the correlations was defined as ≥ 0.30 to 0.49 as weak, ≥ 0.50 to 0.69 as moderate, ≥ 0.70 as strong, and 1.0 as perfect.17 The variables included in the model of multiple linear regression were selected from the correlation analyses. The variables that presented correlation to the number of errors on the questionnaire and that were not highly correlated with each other were tested in the model. The criteria for inclusion were based on p value < 0.10.18 In the final model, only the variables that were statistically significant remained. The level of significance adopted was p < 0.05. The multiple linear regression was designed using the stepwise method. The final model was determined by the adjusted coefficient of determination (R2) and by the statistical significance. To determine the statistical quality of the model, the absence of multicollinearity was verified by the variance inflation factor (VIF>5.0) and normal distribution of residuals by Shapiro-Wilk test and graphic visual analysis (Q-Q plot). The Statistical Package for the Social Sciences v 15.0 (Chicago, IL, USA) and Minitab v. 16 (State College, PA, USA) were used for analyzes.

Two hundred and forty-seven physical therapists were recruited and received a printed copy of the questionnaire. From these, 168 (68%) completed the questionnaires and 79 (32%) refused to participate. Seventy-eight (46%) physical therapists were from public institutions while 90 (54%) were from private institutions. The age of the participants ranged from 23 to 56 years with a mean of 34.0 ± 7.6 years. The duration of professional experience working with patients with respiratory dysfunctions ranged from 1 to 33 years, with a mean of 9.0 ± 7.2 years. Most of the physical therapists worked in hospitals (88.1%), fulfilled a workload of 30 hours per week (70.2%), and had a postgraduate degree as their higher professional degree (84.5%). The proportion of physical therapists with a postgraduate degree in public and private institutions was 94% and 77%, respectively.

Table 1 shows the absolute number and frequency of answers concerning IS concepts addressed by the questionnaire. Participants were also divided into two sub-groups according to the institution they work for (public or private). Most professionals understand the aims of these devices and correctly instruct patients on their use for both types of IS, however, they do not seem to know the main indications and contraindications for IS.

Table 2 shows the instructions provided to patients for ISs use for the total group and for physical therapists from public and private institutions (absolute number and frequency). Half of the sample prescribes the targeted tidal volume in volume-oriented IS according to 5-8 mL/kg predicted body weight.

Table 3 presents information about the use of evidence-based practice. Most physical therapists are aware that the current scientific evidence indicates a superiority of volume-oriented IS compared to flow-oriented IS. A moderate percentage of professionals were aware of the different physiological effects described in the literature for both types of IS. The majority of professionals access scientific databases only when necessary and always in English. Most physical therapists who did not use scientific literature in English worked in private institutions.

The sources to access information ranged from books, scientific articles, co-workers’ experience, courses, and scientific events. Twenty-nine percent of the professionals reported the use of all these options and 13.7% prioritizes the use of scientific articles as the source of information.

Figure 1 presents the aspects related to the choice of an IS type for the total group and for physical therapists from public and private institutions. Most of the physical therapists preferred volume-oriented IS and the main reasons to justify this choice were “scientific evidence,” “equipment available in my workplace,” and “my clinical practice.” Twenty-two percent (37/168) of the physical therapists do not have access to both types of IS in their workplaces, and flow-oriented IS is usually the most available spirometer (53/168). Both IS types are usually found in private hospital and non-hospital institutions, while in a public setting, either for hospital and non-hospital institutions, flow-oriented IS was the most available spirometer.

Fig. 1.

Aspects that influence the selection of an incentive spirometer type. Data were presented in absolute numbers and percentages. IS, incentive spirometers; *, p<0.05 (comparisons between Public and Private institutions). The total number of respondents was 168; 78 from the public sector and 90 from the private sector. Percentages were rounded to clear the illustration.

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The variables age (rho = -0.15, p = 0.049), length of professional experience (rho = -0.24, p = 0.002), workplace (rho = -0.16, p = 0.04), higher professional degree (rho = -0.17, p = 0.03), and use of scientific literature in English (rho = 0.22, p = 0.005) were associated with the number of errors on the questionnaire (Table 4). The length of professional experience and the use of scientific literature in English are the factors, which potentially reduce the number of errors on the questionnaire (R2 = 0.08, p < 0.001).